Corlew, Jeffrey Scott • , /
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NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffrey Scott Corley" Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/11/2022 63 Years Waror Dates
i_ Place of Death Hospital,Institution or
ZCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Mannerof Death EI Natural Cause Accident ❑Homicide ['Suicide Undetermined ❑Pending
W Circumstances Investigation
WMedical Certifier Name Title
O Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
DeaAth Certificate Filed Town or Fort Edward District Number Register Number
City,Town or Village 5755 72
Burial Date Cemetery,Crematory or Facility Name
10/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Q❑Removal Date Place Removed
• and/or and/or Held
fA Hold Address
Q
d Date Point of
th Transportation
Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kikner Funeral Home-South Glens Falls 01078
Address
136 Main St.S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
CC
W •
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrar of Vital Statistics i?imseGMalionsy(Elii'tsrmsthIySO4
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition /0-/3_zs12'Z-- Place of Disposition Q.‘);e- J (/em u- ��
W (address)
W
N Q /stction/ (!o!number) (grow number)
G Name of Sexton or Person' Cha of Premises �� �� 6`01 e`G1`
(please print)
W Signature /Lti. (�— Title C /. !^'Lc. /-/ter/ of e'<ii, 7
DOH-1555(07/18)p 1 of 2
i
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
14.1
II
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#